Patient Referral

For providers: To refer a patient to one of our friendly clinics, please complete the form below (including the patients name and contact details, appointment type, and preferred clinic location) and one of our team will get in touch with the patient directly to organise an appointment.

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Name: Number Dentist

Patient Full Name:

Patient Date Of Birth:

Patient Phone Number

Patient Email

Company Name

Current Dentist

Dentist Email

Dentist Phone

Pick your preferred location *

Select Service

Do you have teeth for immediate extraction?

Which teeth need immediate extraction?

Additional notes

Schedule Your Appointment

Ready to take the next step towards a confident smile?

Scheduling an appointment is easy! Simply give us a call to speak with our friendly team, or fill out our referral form online at your convenience. Whether you need a consultation, denture repair, or custom mouthguard fitting, we’re here to help. Don’t wait – let’s get started on your journey to better oral health!

Request an Appointment